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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application 1s <br /> T- made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> + _ E �� C- sir PM <br /> Job Address City <br /> Owner's Nam dream Phone <br /> Ab- <br /> Contract o dress" License No. Phone <br /> TYPE OF WELL/PUMP: NE. ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> -PUMP INSTALLATION ❑ -SYSTEM-REPAIR ❑. OTHER-0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD: PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> } Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Industrial Ll Open Bottom Ll Manteca <br /> ❑ Domestic/Private'"-,-:.❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑'Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ` rox. Depth ❑ Eastern Surface Seal Installed by <br /> ❑ Irrigation '= � —.SPR P � <br /> Repair Work Oonp Type of Pump H P. State Work:Done <br /> e ; <br /> Well Destruction "❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material iBeiow 501 6 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION STRUCTION'❑ (No septic system permitted if public sewer is J0 <br /> V - t w_ available within 200 feet) <br /> Installation will serve: Residence— Commercial—Z. her <br /> Number of living units: —4 Number of be rooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments <br /> / Method of Disposal i <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well_A26-4-Foundation/41 f' Property Line_ oo!�O ; <br /> LEACHING LINE '�`; No. & Length of lines -22 O Total length/size <br /> f <br /> FILTER-BED ❑ Distance to nearest: Well I Foundation Property Line <br /> SEEPAGE PITS ❑ Depth i Size i Number _ <br /> SUMPS.,. E3 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDSf, ❑ i.,y <br /> I hereby,certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issuedr i shall not <br /> employ any person in such manner as to become subject to workman s compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the.following:"I certify that in-the-performance of the work for which this permit is issued,I-shall employ persons subject to workman's compensa <br /> tion laws of Cali ia." _x j <br /> The applicIn mu call for all required 1 -ctio" CiiI late drawing on reverse side. <br /> �• i , Title: IrT 1 Date: <br /> Signed - �`�' I <br /> -FOR DEPARTMENT,'USE ONLY <br /> Application Accepted by b i a Date Area �y <br /> Pit or"Grout.Inspection by Date Final Inspection b Date <br /> Additional Comments: <br /> ❑ Stk,*466-6781 't ❑ Lodi 369-3621 Hy ❑ Manteca 823-7104 ❑ Tracy 8356385 j <br /> Applicant- Returnall copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St <br /> k., CA 95201 <br /> • R ` <br /> CK X <br /> I E . <br /> i FEE AMOUNT DUE AMOUNT REN41TTED CASH RECEIVED BY DATE - PERMIT NO. <br /> INFO <br /> + EH 13.24(REV.1/a5f77 C ll� 11�--7/ --3s <br /> EH 14-28 �t. pa --'�/� <br />